Pacifica Senior Living Oxnard

Allegation investigated: Staff did not respond to resident's calls for assistance. Staff are not providing residents with food of good quality.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility. LPA met with Executive Director Kortnie Spitznogle at 12:35 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 10/12/2022 regarding staff did not respond to residents's calls for assist and staff are not providing residents with food of good quality. During Resident #1 (R1) interview on 10/13/2022 starting at 3:06 p.m., R1 stated that their pendant was not working for awhile and that it took about thirty (30) minutes for a staff member to respond. R1 added they had a wrist bracelet but was changed to an necklace pendant. R1 also added that the average time to wait for care staff to assist them was about ffteen (15) - twenty (20) minutes long. R1 added, there was once incident in early October that R1 had to urinate but staff never showed up. R1 had an incontinence accident on this occacion. On 10/25/2022, starting at 3:02 p.m., LPA revthe state’s words, verbatim · CDSS document, Oct 25, 2022 · control 29-AS-20221012131509

Allegation investigated: Staff did not keep facility free from pests. Resident’s bathroom is in disrepair due to staff not repairing.

Licensing Program Analyst (LPA) Angel Ascencio conducted an unnanouced, initial complaint visit to the facility above, LPA met with Executive Director Kortnie Spitznogle at 1:16 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 10/12/2022 regarding staff did not keep facility free from pest and resident's bathroom is in disrepair due to staff not repairing. On 10/13/2022, LPA Ascencio conducted an interview with Executive Director (ED) Kortnie Spitznogle at 1:16 pm. ED Spitznogle stated they did find a mouse in the kitchen. ED added that a company came to fix teh air conditioning and left the ceiling hatch open. ED added that they placed traps in the kitchen and were able to catch the vermin in the kitchen. ED also stated they have a company EcoLabs and Teminex coming to the facility to spray the community and get rid of any other vermin if any are found. Based on interview conducted, the allegation staff did not keep teh facilitythe state’s words, verbatim · CDSS document, Oct 13, 2022 · control 29-AS-20221012131509

Allegation investigated: Facility has scabies outbreak

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 11:12 AM to conduct a subsequent complaint investigation for the allegation listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted. During today's visit, LPA Dulek interviewed Administrator at 11:15AM, staff at 11:54AM, and LPA reviewed and obtained copies of pertinent documents. Previously during a subsequent complaint inspection conducted on 04/25/2022, LPA Ascencio toured the facility at 12:30PM, and LPA Dulek requested pertinent documents, however the documents were unavailable at the time of the visit. During an initial virtual complaint visit, which took place on 09/21/2020, LPA Dulek conducted a telephone interview with the RCD and requested pertinent documents, which were not received. During unrelated complaint visits conducted in person at the facility, LPA Dulek conducted staff and resident interviews related to this complaint. The following was then determthe state’s words, verbatim · CDSS document, Sep 23, 2022 · control 29-AS-20200910115337

Allegation investigated: Insufficient staffing Resident's incontinence needs not being met

Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 3:37 p.m., the LPA met with Administrator, Kortnie Spitznogle and explained the reason for the visit. During the initial visit on 06/14/2022, LPAs Emily Peraldi and Zabel Chochian interviewed the Administrator, requested and reviewed pertinent documents between 10:50 a.m. and 1:25 p.m. Additionally, on 06/14/2022, LPA Peraldi and the Administrator conducted a physical plant tour and LPA Peraldi interviewed six (6) out of fifty-three (53) residents and staff between 1:24 p.m. and 3:25 p.m. On 06/24/2022, LPA Peraldi conducted an interview with hospice nurse. In addition, LPA Peraldi subpoenaed hospice agency records and reviewed documents pertinent to the case on 08/04/2022. Continued on LIC 9099-C. Substantiatedthe state’s words, verbatim · CDSS document, Aug 31, 2022 · control 29-AS-20220607135730

Allegation investigated: Facility did not meet reporting requirements

Licensing Program Analyst (LPA) Emily Peraldi conducted an initial 10-day complaint visit at the facility today. At 10:20 a.m., the LPA was greeted and screened by staff. At 11:08 a.m., the LPA met with the Administrator, Kortnie Spitznogle and explained the reason for the visit. Between 11:50 a.m. and 12:15 p.m., LPA Peraldi and the Business Office Manager, Cynthia Garcia conducted a physical plant tour. Between 10:27 a.m. and 12:10 p.m., LPA Peraldi interviewed six (6) out of fifty-four (54) residents and three (3) staff. At 11:10 a.m., LPA Peraldi conducted an interview with the Administrator. At 12:28 p.m., LPA Peraldi reviewed records and obtained copies of pertinent documents. Continued on LIC 9099-C. Substantiatedthe state’s words, verbatim · CDSS document, Jul 13, 2022 · control 29-AS-20220711082056

Allegation investigated: Facility staff did not provide new facility with resident's personal belongings. Facility staff did not clean resident's room. Facility did not provide resident with proper refund.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver final findings. LPA met with Business Office Manager (BOM) Cinthia Garcia at 9:45 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 07/13/2020 alleging that facility staff did not clean resident’s room, facility staff did not provide new facility with resident belonging, and facility staff did not provide proper refund. On 07/22/2020 starting at approximately 11:20 a.m., LPA Kelly Dulek conducted an interview with former ED. During the interview, it was revealed that the facility cleans all the common areas daily and the housekeepers have a schedule for room cleaning with each room being serviced once (1) a week. The housekeepers go into the resident’s rooms and pick up trash, vacuums and clean the restrooms. Continued on LIC 9099 - C Unsubstantiatedthe state’s words, verbatim · CDSS document, May 24, 2022 · control 29-AS-20200713160044

Allegation investigated: Staff are not wearing masks

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver final findings. LPA met with Business Office Manager (BOM) Cinthia Garcia at 9:45 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 05/12/2022 alleging that facility staff are not wearing masks. On 05/17/2022, LPA Ascencio toured the facility at 09:55 a.m. and observed all staff and visitors wearing their mask propely around the community. LPA also witnessed the front desk have a box of surgical mask readily available for staff and visitors if needed. On 05/24/2022 starting at approximately 9:30 a.m., LPA Ascencio toured the comnunity and interviewed staff and residents. Interview with four (4) residents starting at 9:33 a.m. revealed that staff are always seen wearing their mask. Visitors typically wear their mask also but sometimes they just run in real quick and leave. Mask are always available at the front desk. Continuethe state’s words, verbatim · CDSS document, May 24, 2022 · control 29-AS-20220512103100

Allegation investigated: Facility staff is not dispensing medication as prescribed

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 10:01AM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegation listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted. During today's visit, LPA Ascencio toured the facility at 12:30PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and concuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then determined: Report Continued on LIC 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20200519114053

Allegation investigated: Personnel were not trained for the job(s) assigned to them. Facility did not maintain adequate staffing to meet resident(s) needs. Resident(s) call lights are not being answered.

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today with the purpose of delivering findings for the above allegations. The LPA arrived at 10:01AM and met with Executive Director Kortnie Spitznogle. The LPA informed Executive Director of the reason for today's inspection. During today's visit, LPA Ascencio conducted a facilty tour beginning at 12:30PM. During the initial complaint visit on 01/06/2021, LPA Dulek conducted a telephone interview with the administrator at 4:05PM, a video call at 4:24PM, and LPA requested copies of pertinent documents. During a subsequent complaint inspection on 10/26/2021, LPA conducted resident interviews between 11:05AM and 12:50PM. During a previous visit on 10/21/2021, LPA Dulek conducted a facility tour with Business Office Manager Cynthia Garcia and Resident Care Director Marta Tapia at 12:09PM, conducted staff interviews between 12:33PM and 2:30PM and resident interviews between 2the state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20201230085801

Allegation investigated: Staff failed to observe changes in resident's health Facility has ant infestation

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Kortnie Spitznogle and discussed the reason for the visit. Entrance interview conducted. During today's visit, LPA Ascencio toured the facility at 12:30PM. Previously, on 09/02/2020, LPA conducted an initial complaint investigation telephonically, which consisted of a telephone interview with the Resident Care Director, and a video call to conduct a virtual facility tour at 5:27 PM and a review of the pendant/resident call system at 5:36 PM. The LPA requested pertinent documents at that time. LPA then reviewed the documents and interviewed both residents and staff. The following was then determined: REPORT CONTINUED on LIC 9099-C Substantiatedthe state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20200827142152

Allegation investigated: Resident's apartment is not kept at a comfortable temperature

This report was amended on 02/22/2022 to add pertinent information. Licensing Program Analyst (LPA) Angel Ascencio and Kelly Dulek conducted an unannounced complaint visit to the facility above. LPA’s met with Administrator Kortnie Spitznogle at 10:05 am. Entrance interview conducted. It is being alleged that resident's apartment is not kept at a comfortable temperature. On 4/25/2022 starting at 12:32 p.m. to 1:52 p.m. interviews with Resident #1 (R1), R2 and R3 revealed that they have not had any issues with their temperature being to high or too low. When the temperature is needing to be adjusted, resident will call staff for help if they cannot figure it out themselves. During a visit on 02/22/2023, the LPAs checked the temperature in R1’s room and throughout the facility, and conducted additional resident interviews. Room temperatures in six (6) resident rooms and two (2) common areas were tested and was at a comfortable range between 67.5 degree F and 72.7 degree F. Resident interthe state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20220425095729

Allegation investigated: Facility failed to handle outbreak appropriately.

Licensing Program Analyst (LPA) Angel Ascencio conducted an initial complaint investigation to the above facility. LPA met with Administrator Kortnie Spitznogle at 2:35 p.m. LPA and Admin toured the community at 4:30p.m. Entrance interview conducted. It is being alleged that facility failed to handle outbreak appropriately. LPA Ascencio received a telephone call on 4/4/22 at approximately 11:33 a.m from Ventura Public Health Registered Nurse (VCPH). VCPH informed LPA they received an anonymous tip that there was an outbreak at the facility, and it had not been reported and that the building is not doing anything about that. On 4/4/22, LPM Kristin Heffernan, LPA JoAnn Rosales and Ascencio received an email from Long-Term Care Ombudsman (LTCO) that they have been notified anonymously in the morning about a flu or virus outbreak at Pacifica. The anonymous tip described at least 12 residents in memory care. LPA Ascencio reached out to communicate with Admin Kortnie regarding a possible outthe state’s words, verbatim · CDSS document, Apr 12, 2022 · control 29-AS-20220404114101

Allegation investigated: Facility has no Administrator

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA met with Administrator Kortnie Spitznogle and explained the reason for the visit. The report was signed by Resident Service Director Kelly Newcomb as the Administrator had to leave the facility. Based on interviews and record review, the facility administrator at the time of this complaint was Paul Markovich. From approximately 1/13/2021 through approximately 2/8/2021 the administrator was out of the facility due to COVID-19 infection. Two qualified staff were left in charge as acting administrators during that time: Sara Gutierrez and Marta Tapia under the guidance of Paul Markovich by phone. Based on the documentation and interviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2022 · control 29-AS-20210203122326

Allegation investigated: Staff isolating residents from authorized representatives while in care Staff emotionally abuses residents while in care Staff creates fictitious medical reasons for residents without authorization Staff mishandles resident while in care Staff retaliates against residents while in care

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 01:47PM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegations listed above. LPA met with facility Sales Director Matthew Girardot. Facility Executive Director was not available during today’s visit. Entrance interview conducted. During today's visit, LPA, along with Sales Director Matthew Girardot, toured the facility at 01:55PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and conducuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then detethe state’s words, verbatim · CDSS document, Mar 25, 2022 · control 29-AS-20200519123141

Allegation investigated: Resident sustained bed sore while in care Resident not administered medication as prescribed Staff left resident in soiled clothing for extended period of time Facility staff not responding to resident's call button Facility staff not safeguarding resident’s property

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 01:47PM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegations listed above. LPA met with facility Sales Director Matthew Girardot. Facility Executive Director was not available during today’s visit. Entrance interview conducted. During today's visit, LPA, along with Sales Director Matthew Girardot, toured the facility at 01:55PM. No health and safety hazards were observed during today's tour. Previously, on 12/04/2020, between 4:22 p.m. and 5:05 p.m., LPA Dulek conducted an initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with facility designee Sara Gutierrez. The LPA conducted an interview and physical plant tour with the Resident Care Director at 4:25 p.m. The LPA requested copies of pertinent documents relevant to ththe state’s words, verbatim · CDSS document, Mar 25, 2022 · control 29-AS-20201125144906

Allegation investigated: Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care Neglect/Lack of Supervisiion: Facility staff did not seek medical attention for Resident #1 (R1) Staff mismanaging resident’s medication Staff not responding to resident’s call button in a timely manner Resident was left in soiled diaper for extended period of time Staff not providing adequate food service to resident Staff did not safeguard personal belongings

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 03/18/2022 to deliver final findings for the above allegations. The initial visit was conducted on 09/02/2020 by LPA Kelly Dulek and subsequent visits were conducted on 11/4/2021 and 03/15/2022 by LPA Camara. During today’s visit, Administrator Kortnie Spitznogle left the facility to pick up a resident so LPA met with Business Office Manager Cynthia Garcia and explained the reason for the visit. On 09/02/2020, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that former Resident #1 (R1) sustained multiple pressure injuries while in care and facility staff did not seek medical attention for R1. It was reported that the pressure injuries were not discovered until the hospice care intake on 08/20/2020. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson. (continued on pathe state’s words, verbatim · CDSS document, Mar 18, 2022 · control 29-AS-20200902093912

Allegation investigated: Facility did not provide adequate staff to meet resident needs Facility staff did not provide a sanitary environment for residents Resident requires a higher level of care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Kortnie Spitznogel and Cynthia Garcia, Business Office Manager and explained the purpose for the visit is to conclude an investigation initiated on 04/04/2020 by LPA Kelly Dulek. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 03/23/2020, alleging that facility staff did not provide a sanitary environment for residents. LPA Ascencio conducted interviews on 10/21/21 and 10/26/21 with residents and staff. Resident interviews revealed that facility housekeeping comes into the resident rooms to clean the rooms, bathrooms, sweeps and mop at least one (1) time per week. During an interview in resident #1’s (R1) room on 10/26/21, LPA observed a dirty and sticky floor and little bits of paper on the floor. When questioning R1 regarding their room not being clean, R1 responded with “stathe state’s words, verbatim · CDSS document, Mar 18, 2022 · control 31-AS-20200323162113

Allegation investigated: Staff speaking inappropriately to resident while in care Staff failed to effectively communicate with the residents while in care Unqualified staff is providing care and supervision Facility is not providing residents with adequate food Residents are left in soiled diapers for extended periods of time

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations initiated by LPA Kelly Dulek on 04/02/2020. LPA Ascencio met with Administratotr Kortnie Spitznogle and Cynthia Garcia, Business Office Manager at 2:09 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 04/02/2020, alleging that staff is speaking inappropriately to residents while in care. LPA Ascencio interviewed staff and residents between 10/21/21 and 10/26/2021. Interviews revealed that no one in the facility, including staff, have been rude, mean or spoke inappropriately to resident while in care. Residents stated that staff members work hard, are nice are not rude. Further interviews revealed that some care givers go out of their way to do more for residents and threat them with dignity and respect. Based on evidence gathered, the allegation is deemed unsubstantiated at this time. Continued on LICthe state’s words, verbatim · CDSS document, Mar 18, 2022 · control 31-AS-20200402092502

Allegation investigated: Resident is left in soiled diapers for extended periods of time Staff did not give medication to resident

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations initiated by LPA Brian Basili on 05/02/2020. LPA Ascencio met with Administrator Kortnie Spitznogle and Cynthia Garcia, Business Manager at 2:09 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 05/12/2020, alleging that resident is left in soiled diapers for extended periods of time and that staff did not give medication to resident. Interviews with residents on 10/21/21, 10/26/21 and 12/13/21 revealed that the staff help assist residents to use the restroom when the resident push their pendant. Interviews further revealed that it is on rare occasions that residents have to wait for staff to help them out. Interview with Resident #1 could not be conducted as resident no longer resides in facility. Interviews with staff on 10/21/21 revealed that staff check in resident about three (3) times a day or abthe state’s words, verbatim · CDSS document, Mar 18, 2022 · control 29-AS-20200507130645

Allegation investigated: Resident sustained an unexplained injury while in care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Executive Director Kortnie Spitznogle at 10:20 AM. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 06/05/2020, alleging that a resident sustained unexplained injuries while in care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 06/15/2020, 10/20/2020, 12/04/2020, 12/08/2020, 10/4/2021, and 10/21/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents. Continued on LIC - 9099 - C Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 10, 2021 · control 29-AS-20200605113632

Allegation investigated: Staff inappropriately restrained resident while in care.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to close out the allegation at the facility. LPA Ascencio met with Administrator Kortnie Spitznogle at 1:37 p.m. Entrance interview conducted. The Woodland Hills Regional Office (RO) received a complaint on 05/21/2021 alleging that staff inappropriately restrained resident while in care. During the course of the investigation, LPA Ascencio performed interviews, file review and received pertinent documents. Interviews with staff on 08/12/2021, 10/06/2021 and 10/21/021, and revealed that the facility has removed gait belts and other devices from the premise about a year ago. Continued on LIC 9099 - C Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 28, 2021 · control 29-AS-20210521114142

Allegation investigated: Staff are not responding to residents calls for assistance in a timely manor

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to continue investigation. LPA met with Executive Director Kortnie Spitznogle at 10:30 a.m. Entrance interview conducted. It was alleged that staff are not responding to residents call for assistance in a timely manner. Interviews with staff #1 (S1), S2, S3 and S4 on 10/21/21 starting at 12:33 p.m. revealed that all residents in the assisted living side have a call button with them. When residents need help, they push the button alerting staff member on their pagers. Once a call button is pressed, staff head to the room as soon as possible or call for help, shut off the alert button with their own button they have, then help out resident in need. Further interviews revealed that the staff need to respond before the 3rd call on their pager. Continued on LIC-9099-C Substantiatedthe state’s words, verbatim · CDSS document, Oct 26, 2021 · control 29-AS-20200507130645

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegation. LPA Ascencio met with Business Office Manager, Cynthia Garcia at 10:19 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 03/23/2020, alleging that a resident sustained unexplained injuries while in care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 10/20/2020, 12/10/2020, 08/12/2021 and 10/06/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents. Continued on LIC - 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 6, 2021 · control 31-AS-20200323142453

Allegation investigated: Staff are overmedicating residents. Medications are not properly stored and locked. Staff handling residents in rough manner causing skin injury.

Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced, subsequent complaint visit to deliver final investigation findings for the above complaint allegations. Entrance interview conducted. It was alleged that staff were overmedicating residents, as resident #1 (R1) was overmedicated by staff and was transported to the emergency room on 10/13/19. During the course of the investigation, LPA conducted interviews with R1 on 11/22/19 at 1:08 pm, S4, S5 and S6 on 6/5/2020 starting at 12:03 pm. Interviews and information gathered revealed that R1 denied being overmedicated by staff and staff were not aware of R1 ever being over medicated. Furthermore, LPA also gathered and reviewed pertinent documentation on 11/22/19 starting at 10:45 am and on 11/22/19 starting at 10:45 am. Medication records did not reveal that staff were overmedicating R1, and hospital discharge records dated 11/22/19 did not reveal that R1 had any abnormal medication toxicity in R1’s body. Continued on Lthe state’s words, verbatim · CDSS document, Aug 12, 2021 · control 31-AS-20191017141902

Allegation investigated: Severe neglect resulting in death of resident. Resident sustained a fracture while in care. Resident's left in soiled clothing for a long period of time. Resident's room is unsanitary. Facility has a foul odor. Staff failed to meet resident's hygiene needs.

Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced subsequent complaint visit to the above facility to amend technical errors on page 2 of complaint investigation report issued on 8/12/21. It was alleged that severe neglect resulted in the death of Resident #1 (R1). It was further reported that on 09/27/2019, R1 was found deceased in R1s bedroom after sustaining a fall and hitting R1s head. During the course of the investigation, interviews were conducted with S3 and S4 on 10/3/19 starting at 1:47 pm and Hospice Aide on 10/3/19 at 10:57 am. In addition, LPA obtained and reviewed facility documentation pertinent to the allegations on 10/3/19. LPA also obtained and reviewed Hospice documentation on 10/9/19. Continued on LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 12, 2021 · control 31-AS-20191002133729